Employer Response to Employee

(Family and Medical leave Act of 1993)

Date:                                        

To:                                                                                

From:                                                                             

Subject:  Request for Family/Medical Leave

On                                         , you notified us of your need to take family/medical leave due to:
               (date)

the birth of a child, or the placement of a child with you for adoption or foster are; or

a serious health condition that makes you unable to perform the essential functions of your job; or

a serious health condition affection your         spouse,            child,            parent, for which you are needed to provide care.

You notified us that you need this leave beginning on                     and that you expect leave to continue until on or
                                                                                       (date)
about                              .
          (date)

Except as explained below, you have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period for the reasons listed above.  Also, your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued to work, and you must be reinstated to the same or an equivalent job with the same pay, benefits, and term and conditions of employment on your return from leave.   If you do not return to work following FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious health condition which would entitle you to FMLA leave; or (2) other circumstances beyond your control, you may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA leave.

This is to inform you that:   (check appropriate blanks: explain where indicated)

1.  You are         eligible             not eligible for leave under the FMLA.

2.  The requested leave            will            will not   be counted against your annual FMLA leave entitlement.

3.  You         will             will not    be required to furnish medical certification of a serious health condition.   If required, you must furnish certification  by                     (insert date) (must be at least 15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted.

4.  You may elect to substitute accrued paid leave for unpaid FMLA leave.  We             will             will not    require that you substitute accrued paid leave for unpaid FMLA leave.   If paid leave will be used, the following conditions will apply:  (Explain)

5.   

(a)  If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of FMLA leave.  Arrangements for payment have been discussed with you and it is agreed that you will make premium payments as follows: (Set forth dates, e.g., the 10th of each month, or pay periods, etc. that specifically cover the agreement with the employee.)

(b)  You have a minimum 30-day (or, indicate longer period, if applicable) grace period in which to make premium payments.  If payment is not made timely, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share of the premiums during FMLA leave, and recover these payments from you upon your return to work.  We         will             will not    pay your share of health insurance premiums while you are on leave.

(c)  We         will             will not  do the same with other benefits (e.g., life insurance, disability insurance, etc.) while you are on FMLA leave.  If we do pay your premiums for other benefits, when you return from leave you         will             will not be expected to reimburse us for the payments made on your behalf.

6.   You         will             will not be required to present a fitness-for-duty certificate prior to being restored to employment.  If such certification is required but not received, your return to work may be delayed until certification is provided.

7.

(a)  You         are             are not  a "key employee" as described in subsection 815.219 of the FMLA regulations.   If you are a "key employee," restoration to employment may be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us.

(b)  We         have             have not   determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to us. (Explain (a) and/or (b) below.   See subsection 815.219 of the FMLA regulations.)

8.  While on leave, you         will              will not   be required to furnish us with periodic reports every         (indicate interval of period reports, as appropriate for the particular leave situation) of your status and intent to return to work (see subsection 815.309 of the FMLA regulations).  If the circumstances of your leave change ad you are able to return to work earlier than the date indicated on this form, you          will             will not be    required to notify us at leave two work days prior to the date you intend to report for work.

9.  You         will             will not    be required to furnish recertification relating to a serious health condition. (Explain below if necessary, including the interval between certifications as prescribed in subsection 815.308 of the FMLA regulations.)